Four Humors Medieval
It is not hard to learn more. What is hard is to unlearn when you discover yourself wrong (1). ~Martin H. Fischer
In the frightening time of the Black Plague, many held strong beliefs about how the disease spread. Clergy claimed it was a punishment directly from God; Hippocratic physicians said it was an imbalance of the body’s four humors; Astrologers attributed it to the proximity of Jupiter, Saturn and Mars; the public was told that bathing and exercise were risky because they opened one’s pores; some even said it could be passed through an evil stare (2, 3). We can only imagine the pervasive panic, fear and misunderstanding that drove people to all sorts of ineffective “preventive” behaviors.
Even when the true cause of the Plague was discovered, I wonder how long it took for people to actually believe the real scientific explanation, or begin bathing and making eye-contact once hearing that their previous beliefs were incorrect.
While we may think of ourselves today as a scientific society—able to release established beliefs and modify our approaches when new information comes along—maybe we aren’t so different from our medieval ancestors. All tightly-held beliefs are scary to let go.
First, an admission: I have been through my own sort of Dark Ages, holding on to an entrenched way of thinking, perpetuating what I ultimately learned was a counterproductive approach to health and healthcare management. Ten years ago, I believed that I understood the primary causes of high health care costs and utilization. I was paid to speak and write about it—which I did to the best of my ability. The process of discovering that I was, in fact, wrong, struck me as—in order—puzzling, humbling, frightening, and then enlightening and even promising. But I admit, early in the uncomfortable phase of learning a new paradigm, it was tempting to simply say, “Don’t tell me,” or “This is irrelevant,” knowing that no one would likely ever find out. It was the first time I understood the meaning of “ignorance is bliss.”
I needed to admit I had been wrong, or at the very least overly narrow, in my perspective about corporate health and the causes of sharp increases in healthcare costs.
Truly, I understand that changing our minds is not easy, and can even be threatening to our egos and livelihoods. But I also discovered that admitting I was wrong led to real solutions and brought meaningful contribution to a field in need of new ideas.
Whew. New explanations come as a relief.
Once I got over my dread of admitting I was wrong, it was an incredible relief to understand WHY THINGS DIDN’T WORK the way I expected. I could now explain why medical costs were high in groups who were supposedly very “healthy.” I could explain why the same health program could succeed in one organization and fail miserably in another. The perplexing mysteries of why two people with the same disease could behave so dramatically differently suddenly weren’t so mysterious any more.
Essentially, the new ideas were these: What if the relationship between health status and benefits costs has been vastly overstated? And instead, we can explain a lot about healthcare costs and business outcomes using economic observations like these:
- Overall, medical costs are an inaccurate measure of health status. Two people with the same illnesses at the same level of severity will not seek or receive the same healthcare services. Many, many other factors—especially economic, but also social, occupational, beliefs and perceptions—will influence how much healthcare different people demand and consume (4).
- Rates of disability insurance claims are a poor indicator of significant healthcare needs. Rates of disability vary dramatically due to economic incentives, wage compensation, job and family circumstances (5, 6).
- Medical cost differences between groups reflect a wide array of factors, surprisingly little of which is health status. Particularly when business practices or benefit designs create perverse economic incentives, healthcare cost differences are nearly impossible to trace to actual differences in health status or geography (4).
- A population getting more care is not necessarily sicker, nor are they getting better care for each additional dollar spent. Too often, it is quite the opposite (7, 8, 9).
- Use of healthcare and disability insurance is not proof of medical problems or always reflective of severity. If someone interacts with the medical system, he or she will receive a medical label simply because there is no other way for physicians to bill for their services. If the cause of a visit is more socially-driven than medical, the claim will still be labeled as medical.
- Health intervention programs, while well-intended, are rarely an employer’s best chance at reducing healthcare and absence claims. Most employers can have a greater impact on the costs AND health of their workforces by altering non-health-related practices (such as compensation, paid time-off, manager training and other factors) than by intervening to try to influence an individual’s health status directly (10, 11).
- If we only look at indicators of medical problems, we will only find more disease-focused solutions to try. As they say, if you only have a hammer…everything looks like a nail. Attempts by employers to improve health will not manage costs unless other factors are aligned first.
- When a company aligns its business practices in ways that help employees be successful at their jobs, healthcare costs go down and employees pay more attention to their own well-being. The side-effect of good business practices is better health—meaning that maybe we have been trying to solve the health problem in the wrong way (12).
There’s no going back.
Before, when I was advocating that the best way to reduce healthcare costs was to add an ever-growing list of health improvement programs in every company, this list of statements was frightening. How would I explain my previous recommendations? What might my colleagues say? (And they did say: “What HAPPENED to you?”).
But, faced with strong economic evidence and clear, repeated examples, there was no denying it. There is a better way to improve health, enhance business performance, and save money; I couldn’t honestly say otherwise. Most gratifying, what I learned was helping improve the health, careers, and business performance of workers and organizations.
Many people I talk to like the other explanation better.
And to them: I get it. New answers can be threatening to our belief systems, egos, and careers.
But new answers also help us explain more, achieve better outcomes, and become more efficient. For the sake of future companies and employees, I hope those folks reconsider. Who knows, like bathing, maybe it will make the world a better place?
Why this matters: Resistance to new ideas, especially disruptive ones, is natural. Life seems easier when we can stick with what we know. But there are significant opportunities to improve both health and business outcomes by changing the way we understand the drivers of cost. A new understanding of a problem can reveal different—and sometimes better—solutions.
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References
(1) Fischer, M. H. Science Quotes by Martin H. Fischer (accessed November 20, 2009).
(2) Benedictow, O. J. The Black Death 1346-1353: The Complete History. DS Brewer; Feb 2006.
(3) Britain Express. The Black Death in England 1348-1350 (accessed November 20, 2009).
(4) Self-Care Institute. Demand Management Handbook. Washington, DC: Partnership for Prevention; 1996.Health as Human Capital Foundation.
(5) Money matters in decisions about disability. Entry 2 - 2005 . Sep 27 2005 (accessed November 20, 2009).
(6) ---. Getting value from health benefits: Use them or lose them Entry 18 - 2007. Aug 26 2007 (accessed November 20, 2009).
(7) Lynch, W. D.; Edington, D. W., and Johnson, A. Demand management. Predicting the demand for healthcare. Healthc Forum J. 1996 Jan-1996 Feb 28; 39(1):20-4.
(8) Fisher, E. S.; Wennberg, D. E.; Stukel, T. A.; Gottlieb, D. J.; Lucas, F. L., and Pinder, E. L. The implications of regional variations in medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003 Feb 18; 138(4):273-87.
(9) --- The implications of regional variations in medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003 Feb 18; 138(4):288-98.
(10) Health as Human Capital Foundation . How much does health drive healthcare costs anyway? Entry 20 - 2009. 2009 Sep 27 (accessed October 8, 2009).
(11) ---. Part IV: Business Practices—A major, modifiable driver of healthcare costs. Entry 21 - 2009. Oct 11 2009 (accessed October 22, 2009).
(12) ---. Money Matters. What do skinny people in big houses have to do with flu shots and bonus pay? Entry 11 - 2008. May 26 2008 (accessed June 5, 2008).
Hello Folks,
“What, two posts in one week?” you may be asking yourself “has he gone insane?” Well yes I have gone insane actually, but in a good way: insane with ideas (the best kind of insane).
Over the last few days, i’ve been toying with the idea of writing a chapter on water symbolism that is, in effect, an art history chapter (something that excites me). Since I am effectively arguing within my thesis that water symbolism (and indeed all symbolism) is not simply a byproduct of the imagination process, but part of a process of imaginative hermeneutics in which the imagined feeds back into the imaginer. This is, as I realized yesterday, a narration of ontology (being) through symbolism. This is important, because almost all of the symbologists, medievalists and other scholarly experts that I have read assume that symbolism is the byproduct of a world-view. I will argue that symbol and idea exist in a state of reciprocity, engaging in a two-way dialogue to produce meaning. This is a particularly important point when one is studying the Middle Ages, for this symbolic correspondence was planned: it was imagined as the method by which an omnipotent God spoke to His creations through Creation itself (compare this comment with some of the secondary source quotes in my last post regarding epistemology and symbolism).
Now at this point you may be asking yourself, “where are the pictures, he promised me pictures!” Fear not, gentle reader, for I will now show you some beautiful images. Most are from a particularly beautiful French manuscript of Bartholomaeus Anglicus’ De proprietatibus rerum (on the properties of things) from the late 14th century by Jean Corbechon, entitled Livre de propriétés de choses.
This image comes from Bartholemaeus, and depicts the four elements of the cosmos surrounded by the signs of the zodiac. I particularly like the way that wind kind of looks like a series of gribbly tentacles (I mean, how else do you draw wind I suppose). This picture, although simple, depicts the disparate yet unified nature of the cosmos. The circles represent the world (inner circle) within the cosmos (the celestial realm) – the word mundus means both world and cosmos in Latin, a duality containing what Hugo Rahner described as ‘typical Latin pregnancy’ – for the circle was a perfect shape, without division or flaw. It was the sphere that represented creation, for it is one (the generator of all integers) reflecting the undivided nature of its Creator. The number four was a number of balance, an appropriate number for the elements that, through their interrelationship, defined the order of the world. In the words of Clement of Alexandria, ‘Righteousness is Quadrangular’, for four was the first wholly even number, and thus stood in balance despite its multiplicity.
In this image, we see the balance of four applied to the human body, the little world or minor mundus within the ‘big world’. In this image, the four humors of the body are linked to their elemental companions. Blood, Phlegm Choler and Black bile were tied to Fire, Earth, Wind and Water in addition to Hot, Cold, Wet and Dry. As we can see in this image, humanity exists in between these extremes, with a hand or foot in each corner of creation, splayed between competing forces. If once could balance these principles then one would be healthy, but if an imbalance occurred (discrasia), then sickness and emotional disturbance would follow.
This image shows the dichotomy of body and soul, a cause for concern (for humanity should be one), yet also a reminder of our spiritual dimension. The body exists superimposed over the soul (the glowing yellow). The flesh was heavy, stolid and earthly, and had no place in the spiritual realm; the soul was ascendant, floating the the top like fire, ascending the heavens and communing with the Divine Intellect.
This is my last image, and a personal favorite. It comes from a 13th century moralized Bible, and shows an image of the Divine Architect using his compass to measure and differentiate the cosmos during the Hexaemeron, or six days of Creation. This image is interesting, because it shows an occasionally occurring notion of the cosmos as an egg. The world in this image is quite distinctly yolk-like, suspended within the albumen (white), representing the water (note the womb symbolism); the shell is the sky and the membrane the aether.
So there we go: hopefully you can see that it is possible to narrate the nature of Creation, time, life, the body etc through symbolism. The symbols in these images are not merely side-effects, they signify extremely complex metaphysical concepts that take pages and pages to explain in full. A picture does mean a thousand words when medieval symbolism is concerned, and is of particular importance when you remember that the ‘thousand words’ option was only available to a very small percentage of medieval society. Images such as these had to tell an entire story, and often defined one’s understanding of the forces shaping the cosmos.
Best Wishes,
James.
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